<!-- 法人サイト専用お問い合わせ入力画面 -->
<div id="main">
	<!-- InstanceBeginEditable name="main" -->
	<h1 id="specialTitle">本サイトに関するお問い合わせはこちらから</h1>
	<!-- siteContents -->
	<div id="siteContents">
		<div id="formBlock">
			<p class="bar"><img src="/images/inquiry/hp/form/img_bar_01.jpg" alt="お客様情報の入力" width="720" height="32" /></p>
			
		</div>

		<div id="formBlock">
			<table id="inqHouseForm">
			<tbody>
				<tr>
					<th>お名前&nbsp;<span class="attTxt">[必須]</span></th>
					<td><p>（姓）<input name="NameSei" id="NameSei" value="{$NameSei}" type="text" maxlength="10" style="IME-MODE: active" class="inputBox01 required zenkaku" />
							（名）<input name="NameMei" id="NameMei" value="{$NameMei}" type="text" size="20" maxlength="10" style="IME-MODE: active" class="inputBox01 required zenkaku" /></p>
						<p class="errTxt" htmlfor="NameSei" generated="true" />
						<p class="errTxt" htmlfor="NameMei" generated="true" />
					</td>
				</tr>
				<tr>
					<th>年齢</th>
					<td>
					<select name="AgeKbn" id="AgeKbn">
						<option value="0" {if $AgeKbn == 0 } selected {/if}>選択してください</option>
						<option value="1" {if $AgeKbn == 1 } selected {/if}>18歳未満</option>
						<option value="2" {if $AgeKbn == 2 } selected {/if}>20歳未満</option>
						<option value="3" {if $AgeKbn == 3 } selected {/if}>20～24</option>
						<option value="4" {if $AgeKbn == 4 } selected {/if}>25～29</option>
						<option value="5" {if $AgeKbn == 5 } selected {/if}>30～34</option>
						<option value="6" {if $AgeKbn == 6 } selected {/if}>35～39</option>
						<option value="7" {if $AgeKbn == 7 } selected {/if}>40～49</option>
						<option value="8" {if $AgeKbn == 8 } selected {/if}>50～59</option>
						<option value="9" {if $AgeKbn == 9 } selected {/if}>60歳以上</option>
					</select>&nbsp;
					</td>
				</tr>
				<tr>
					<th>性別</th>
					<td>
						<input type="radio" name="Sex" id="Sex0" value="0" {if $Sex == 0 } checked {/if} />
						<label for="sex1">男性</label>
						<input type="radio" name="Sex" id="Sex1" value="1" {if $Sex == 1 } checked {/if}  />
						<label for="sex2">女性</label>&nbsp;
					</td>
				</tr>
				<tr>
					<th>電話番号</th>
					<td>
						<input type="text" name="Tel1" value="{$Tel1}" id="Tel1" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled" />
						－
						<input type="text" name="Tel2" value="{$Tel2}" id="Tel2" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled" />
						－
						<input type="text" name="Tel3" value="{$Tel3}" id="Tel3" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled" />
						<p class="errTxt" htmlfor="Tel" generated="true" />
					</td>
				</tr>
				<tr>
					<th>FAX</th>
					<td>
						<input type="text" name="Fax1" value="{$Fax1}" id="Fax1" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled" />
						－
						<input type="text" name="Fax2" value="{$Fax2}" id="Fax2" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled" />
						－
						<input type="text" name="Fax3" value="{$Fax3}" id="Fax3" maxlength="4" class="inputBox03 number" style="IME-MODE: disabled" />
						<p class="errTxt" htmlfor="Fax" generated="true" />
					</td>
				</tr>
				<tr>
					<th>メールアドレス&nbsp;<span class="attTxt">[必須]</span></th>
					<td>
						<p><input type="text" name="Mail" value="{$Mail}" id="Mail" maxlength="50" class="inputBox02 required email alphanum" style="IME-MODE: disabled" /></p>
						<p class="errTxt" htmlfor="Mail" generated="true" />
					</td>
				</tr>
				<tr>
					<th>お問い合わせ内容&nbsp;<span class="attTxt">[必須]</span><br/><span class="attTxt">(500字以内でお願い致します)</span></th>
					<td>
						<textarea name="Comment"  id="Comment" class="required maxlength" maxlength="500" cols="60" rows="5" style="ime-mode:active">{$Comment}</textarea>
						<p class="errTxt" htmlfor="Comment" generated="true" />
					</td>
				</tr>
			</tbody>
			</table>

			<p id="privacyTxt">▼必ずお読みください。</p>
			<div id="privacyTitle">
				<p class="txt">個人情報の取り扱いについて</p>
				<p class="link"><a href="http://www.fcapamanshop.com/privacy.html" target="_blank">別ウィンドウで見る</a></p>
			</div>
			<div id="privacyContents">
				<iframe width="100%" scrolling="auto" height="165" frameborder="no" src="/app/html/inquiry/privacy.html" id="privacy"></iframe>
			</div>

			<table class="footTable">
			<tbody>
				<tr>
					<td></td>
					<td class="attTd">SSL暗号化通信を使用してますので、安心して個人情報を送信いただけます。</td>
					<td></td>
					<td class="pointTxt">
						<a href="#link" onclick="javascript:etcEntryConf(); return false;" onKeypress="javascript:etcEntryConf(); return false;" class="links">入力内容を確認して送信</a>
					</td>
					<td>
						<a href="#link">
							<img width="271" height="66" class="rollImg" alt="「個人情報の取り扱いについて」に同意の上今すぐ送信" src="/images/search/detail/btn_send_now.jpg"onclick="javascript:etcEntrySend(); return false;" onKeypress="javascript:etcEntrySend(); return false;" />
						</a>
					</td>
				</tr>
			</tbody>
			</table>
		</div>

	</div>
</div>

<!-- 共通パラメータここから -->
<input type="hidden" id="ComId" name="ComId" value="{$ComId}" />
<!-- 共通パラメータここまで -->
